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School Attendance Review Board (SARB) Referral

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SARB first step
Attachments

Referral Date

**

District

*

School

*

Student/Family Information

Student First Name

**

Student Last Name

**

Preferred Name

*

Date of Birth

**

SSID

***

SSID must be exactly 10 digits

Grade

*

Gender

*

Preferred Pronouns

Ethnicity

*

Race 1

*

Race 2

*

*

*

Student Physical Address

*

Address Line 1

*

Address Line 2

*

City

*

State/Province

*

Zip/Postal

Mailing Address (if different)

*

*

*

City

*

State/Province

*

Zip/Postal

Parent/Guardian 1

First Name

**

Last Name

**

Phone

**

Same Address as Student?

*

Same Address as Student? NoSame Address as Student? Yes

Physical Address - Parent/Guardian 1

*

*

*

City

*

State/Province

*

Zip/Postal

Mailing Address (if different) - Parent/Guardian 1

*

*

*

City

*

State/Province

*

Zip/Postal

Parent/Guardian 2

First Name

*

Last Name

*

Phone

*

Same Address as Student?

Same Address as Student? NoSame Address as Student? Yes

Physical Address - Parent/Guardian 2

*

*

*

City

*

State/Province

*

Zip/Postal

Mailing Address (if different) - Parent/Guardian 2

*

*

*

City

*

State/Province

*

Zip/Postal

Primary Language

*

Interpretation Needed

*

Interpretation Needed NoInterpretation Needed Yes

IEP

*

IEP NoIEP Yes

IEP Attendance Goal

IEP Attendance Goal NoIEP Attendance Goal Yes

Is the student/family involved in Child Welfare/Foster Youth Services?

*

Is the student/family involved in Child Welfare/Foster Youth Services? NoIs the student/family involved in Child Welfare/Foster Youth Services? Yes

Is the student/family involved in McKinney-Vento Homeless Youth Services?

*

Is the student/family involved in McKinney-Vento Homeless Youth Services? NoIs the student/family involved in McKinney-Vento Homeless Youth Services? Yes

Does the student have siblings in ANY school district

*

Does the student have siblings in ANY school district NoDoes the student have siblings in ANY school district Yes

List Siblings

Sibling Name

*

Age

**

District

*

School

*

Add Another Sibling Add Another SiblingAdd Another Sibling Remove

Sibling Name

*

Age

*

District

*

School

*

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Sibling Name

*

Age

*

District

*

School

*

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Sibling Name

*

Age

*

District

*

School

*

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Sibling Name

*

Age

*

District

*

School

*

adddropsib41 Yesadddropsib41 No

Sibling Name

*

Age

*

District

*

School

*

adddropsib51 Yesadddropsib51 No

Sibling Name

*

Age

*

District

*

School

*

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Sibling Name

*

Age

*

District

*

School

*

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Sibling Name

*

Age

*

District

*

School

*

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Sibling Name

*

Age

*

District

*

School

*

Agencies/services with which the student/family is currently involved

*

Other Agencies/Services

*

Health Issues

*

Additional Supports in Place

*

Student Attendance Patterns

School Days Since Enrollment

***

Days of Excused Absences

***

Days of Unexcused Absences

***

Days Tardy >30 Minutes

***

Indicate number of DAYS, not number of periods

Days Suspended

***

Days Cut Classes

***

Is there a SARB from the Previous Year?

*

Family Explanation of Barriers

*

Conferences Held or Attempted

*

Other Conferences held or Attempted

*

Date(s) Student Study Team Meeting Held or Attempted

*

Date(s) Student Attendance Review Team

*

Date(s) Parent Conference Held or Attempted

*

Date(s) of Home Visit(s)

*

Describe the Situation and Interventions/Supports Applied or Attempted

Summarize the Situation

**

Person Completing This Form

**

School Principal/Administrator Name

**

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